Stroke in cancer patients is not infrequently encountered. Although both hemorrhagic and ischemic stroke can occur with cancer-associated coagulopathy, not all strokes in cancer patients can be attributed to cancer. In 1965, a French physician Armand Trousseau reported three patients presenting with migratory phlebitis who were later diagnosed as having cancer. Thus, the Trousseau syndrome does not necessarily refer to cerebral infarction. In fact, venous thromboembolism (deep venous thrombosis and pulmonary embolism) is the most frequent complication of cancer-related coagulopathy. As for stroke, nonbacterial thrombotic endocarditis (NBTE) is the most common type of stroke in cancer patients. Tiny sterile fibrin-platelet thrombi attached to the cardiac valves without destruction cause multiple cerebral infarctions in different arterial territories. The exact mechanism of NBTE in cancer patients remains to be established and intravenous thrombolysis with alteplase is not contraindicated. However, unexpected and devastating cerebral hemorrhage can occur after thrombolysis. Although unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or synthetic Xa inhibitors can be used to prevent the recurrence of stroke, long-term usage is often difficult because of disseminated intravascular coagulation (DIC) and exacerbation of the cancer status. Warfarin has been thought to be less effective, and non-vitamin K antagonist oral anticoagulants (NOACs) could be an alternative choice, but cogent evidence remains to be established at present.

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Recently, balloon catheters are generally used as a successful embolization for wide-necked cerebral aneurysms. We report four cases of aneurysm embolization using the balloon remodeling technique with the new double-lumen balloon catheter, Scepter C/Scepter XC, which can resolve several issues in single-lumen balloon catheter, HyperGlide/HyperForm. All cases were achieved with complete obliteration or neck remnant without any hemorrhagic and ischemic complications. A new double-lumen Scepter balloon catheter is a safe and effective device for use in balloon remodeling for aneurysm coil embolization.

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Purpose and Method: We retrospectively examined the associations among left atrial thrombus, anticoagulant therapy, and recurrent thromboembolism in 237 patients with nonvalvular atrial fibrillation (NVAF) who had undergone transesophageal echocardiography (TEE) within 7 days after the onset of thromboembolism. Results: TEE detected a left atrial thrombus in 73 patients (31%). Thromboembolism recurred within 1 month after TEE in 10 (13.7%) of the 73 patients who were positive for a left atrial thrombus and 8 (4.9%) of 164 thrombus-negative patients (p<0.05). In the left atrial thrombus-positive group, the recurrence rate was significantly lower in 40 patients receiving anticoagulant therapy as compared with 33 patients not receiving anticoagulant therapy (5.0% vs. 24.2%, p<0.05). Meanwhile, in the left atrial thrombus-negative group, the recurrence rate in 102 patients receiving anticoagulant therapy was 3.9%, showing no significant difference from 6.5% in 62 patients not receiving anticoagulant therapy. Conclusion: A left atrial thrombus increased the recurrence rate in patients with NVAF in the acute phase of thromboembolism, and early-stage anticoagulant therapy significantly decreased the recurrence rate.

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A 78-year-old man was admitted to our hospital because of right hand weakness due to small cortical infarction at left precentral gyrus. Neck MR angiography revealed left neck internal carotid artery stenosis. The stenotic part was fragile plaque with intra-plaque hemorrhages. We performed carotid artery stenting (CAS) approximately 2 months after the onset. Because fragile plaque was suggested, we chose the distal protection using the Carotid GuardWire PS (Medtronic, Santa Rosa, CA, USA), not a filter. Immediately after the distal balloon was inflated on trial, the patient presented right side hemiparesis, aphasia, and consciousness disturbance. Carotid Wall stent (Boston Scientific Natick, MA, USA) was placed in a rapid manner under sedation. Total occlusion time was 8 minutes 50 seconds. After the distal balloon became deflated, his symptoms did not disappear regardless of any distal embolisms in the final angiography. Three hours later, his right hemiparesis was recovered almost fully, but his aphasia continued. At last, his neurological deficits disappeared completely after 2 days. The CAS procedure using balloon protection has problems about the ischemic intolerance. Commonly, the symptoms of intolerance are improved rapidly after restore patency of blood flow. In this case, ischemic symptoms prolonged for 2 days in spite of cerebral infarction not being seen. It was thought that the ischemic intolerance purely caused this symptom.

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A 47-year-old woman presented with severe headache, and subsequently unconsciousness followed 4 days after onset. As for the patient, combined drugs of Norethisterone and Ethinylestradiol had been administrated for the endometriosis from 3 years before onset. Head CT revealed acute sub-cortical hemorrhage with peri-focal edema in the left occipital lobe, and the left sigmoid sinus showed higher density than the right one. Because subsequent cerebral angiography revealed occlusion of the left sigmoid sinus, the venous sinus thrombosis was diagnosed as a possible cause of the stroke. After confirming hemostasis by the followed CT on the next day, anticoagulation therapy was induced, and the patient was discharged with slight speech disturbance and homonymous quadrantanopsia 21 days after admission. Oral contraceptives are well known as causes of cerebral venous thrombosis, and combined drugs of Norethisterone and Ethinylestradiol consists of the same component of the first generation low dose oral contraceptives. Because the patient had no other risk factors causing venous thrombosis, the authors determined that the venous thrombosis was affected by this drug. Because administration of the combined drugs of Norethisterone and Ethinylestradiol for endometriosis can be covered by insurance in Japan, the administrated cases can increase from now on. Therefore, enlightenment for the risk of venous thrombosis should be announced both to the doctors, who administrate combined drugs of Norethisterone and Ethinylestradiol and to the patients, to whom this drug is administrated.

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Case 1: A 63-year-old man developed right vertebral arterial dissection with an aneurysm of 6 mm and headache after neck rotation. After commencement of antihypertensive treatment, the symptom of headache improved and disappeared on the 17th disease day. And he was discharged on the 26th disease day. Case 2: A 39-year-old man developed headache suddenly in the morning. MRA examination showed right arterial dissection with an aneurysm of 9 mm. Antihypertensive treatment was started and the headache disappeared on the 17th disease day. And he was discharged on the 23rd disease day. Follow-up MRA examination demonstrated disappearance of the aneurysm in both the cases. It seems that antihypertensive treatment for patients with vertebral artery dissection is effective to improve headache and in dissecting lesions.

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A 62-year-old man presented with left lateral medullary infarction and had no dysphagia. After 2 years from the infarction, right lateral medullary infarction occurred, and the patient showed dysphagia. Because of the infarction, the patient suffered from severe aspiration pneumonia twice, and eventually recovered. Based on imaging studies, the infarction was presumed to be caused by atherosclerotic thrombosis. Bilateral lateral medullary infarction is extremely rare and could cause severe aspiration pneumonia, which we should be cautious about.

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A 77-year-old man on dabigatran 110 mg BID for prevention of stroke associated with nonvalvular atrial fibrillation developed transient speech disturbance for 15 min. Transesophageal echocardiographic examination demonstrated an intracardiac mobile thrombus at the left atrial appendage. We changed anticoagulant therapy from dabigatran 110 mg BID to rivaroxaban 15 mg QD. Serial transthoracic and transesophageal echocardiographic examinations showed the thrombus reducing in size, disappearing by day 13 without any recurrence of neurological deficit. For the treatment of NVAF patients with intracardiac thrombi, rivaroxaban 15 mg QD may be superior to dabigatran 110 mg BID.

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We report the case of an 81-year-old man with a progressive atherothrombotic cerebral infarction at posterior circulation. He suddenly complained of nausea, vertigo, and vomiting. His neurological findings showed dysarthria, nystagmus to left side, and limb ataxia of the right arm. Brain MRI and MRA showed cerebral infarctions on the right hemisphere of the cerebellum and the left occipital lobe with severe stenosis in the vertebral and basilar arteries. He was treated with argatroban by dual antiplatelet therapy. After argatroban was discontinued at day 5, clinical symptoms became worse and new infarctions appeared in the brainstem and at the left side of cerebellar hemisphere. Therefore, heparinization was started and the clinical symptoms became stable. Based on the sudden neurological worsening after discontinuation of argatroban, we speculate that anticoagulation would be necessary to prevent worsening and recurrence in the acute stage of atherothromobotic brain infarction.

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We assessed the utility of lemon fruit juice for the purpose of stabilizing tubal-feeding agents and shortening the feeding time. We examined the efficacy and safety of adjunctive administration of lemon fruit juice. Along with our previous report, we injected lemon fruit juice, whose amount was 5% of the nutrition, just before the administration of nutrition through naso-gastric tube in seven patients with acute stroke who needed to be fed transnasally because of dysphagia. During the observation, the gastrointestinal symptoms including diarrhea and vomiting were not increased after the injection of lemon fruit juice. Although it usually takes 1.5-2 hours to administrate the nutrition transnasally, we were able to administrate it within 20 minutes by using the adjunctive injection of lemon fruit juice. Our study indicates that adjunctive use of lemon fruit juice can shorten the feeding time leading to spend more time for rehabilitation. No obvious side effect was seen in this study, indicating the possibility of efficacy and safety in this more simple and convenient strategy of tube feeding. Large-scale study should be done for further evaluation of this new strategy.

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